RECORDING THE PATIENT
ENCOUNTER
Scott R Snyder BS, NREMTP
SRJC
AGENDA
• Review
patient assessment and management
• Reviewing
• Talk
charting
about the relationships between the two
• Practice
charting
PATIENT ASSESSMENT &
MANAGEMENT
Scene Size-Up
Secondary Exam
HPI
Treatment
Vital Signs
Status Determination &
Transport Decision
General
Impression
Transfer of Care
Primary Exam
Ongoing
Assessment
Scene Size-Up
General
Impression
Status Determination &
Transport Decision
Vital Signs
HPI
Treatment
Ongoing
Assessment
Secondary Exam
Transfer of Care
Primary Exam
Scene Size-Up
General
Impression
Primary Exam
Treatment
Status Determination &
Transport Decision
Transfer of Care
SCENE SIZE-UP
• What
are the important components?
GENERAL IMPRESSION
• Age
• Gender
• LOC
• Position
• Chief
Complaint
Form a general
impression...
52 y/o M presents L lat recumbent on
sidewalk alert to pn only s complaint.
WHAT’S YOUR GENERAL
IMPRESSION?
• Time
for a little bit of work
HPI
• For
both trauma and medical
• Describe
the MOI
• Describe
the NOI
HPI: DESCRIBING THE MOI
• How
do we do it?
• Important
involved
info = strength, nature, and direction of forces
Pt was unbelted passenger in left window seat of school
bus that rolled over onto R side and slid 20 ft prior to
coming to stop. Driver reports he was traveling at 45
mph on wet road surface, swerve to avoid hitting dog in
road, overcorrected. Bus did not strike other vehicles or
structures, came to stop on own. Damage to R side of
bus only.
HPI: DESCRIBING THE NOI
• Get
the story!
• SAMPLE
• OPQRST
PERTINENT NEGATIVES
• Abd
pn
• Back
pn
• Headache
• Weakness
• Syncope
• CP
• SOB
• Dizz
• N/V
SECONDARY EXAM
VITAL SIGNS
• RR
• HR
• BP
• SpO2
TREATMENT
ONGOING ASSESSMENT
• Repeat
vital signs
• Repeat
primary exam as needed
• Repeat
secondary exam as needed
WHO DID YOU REPORT TO?
• Report
given to:
• ER Tech?
• RN
• NP/PA
• MD/DO
ACCURATE CHARTING
• Why
bother?
SOAP
• Subjective:
What you’re told
• Objective:
What you figure out
• Assessment:
• Plan:
What you think
What you do
Scene Size-Up
General
Impression
Primary Exam
Status Determination &
Transport Decision
Secondary Exam
Vital Signs
SOA P
HPI
Treatment
Transfer of Care
Ongoing
Assessment
S
HPI
O
Scene Size-Up
General
Impression
Primary Exam
Secondary Exam
Vital Signs
P
A
Status Determination &
Transport Decision
Treatment
Ongoing
Assessment
Transfer of Care
CHART
• Chief
complaint
• History
• Assessment
• Rx
= treatment
• Transport
HPI
C H A R T
Status Determination &
Transport Decision
Scene Size-Up
General
Impression
Primary Exam
Secondary Exam
Vital Signs
Treatment
Ongoing
Assessment
Transfer of Care
C
H
General
Impression
Scene Size-Up
HPI
A
R
Primary Exam
Status Determination &
Transport Decision
T
Ongoing
Assessment
Secondary Exam
Treatment
Vital Signs
Transfer of Care
CHEATED
• Chief
complaint
• History
• Exam
• Assessment
• Treatment
• Evaluation
• Disposition
General
Impression
C H E ATED
Primary Exam
Scene Size-Up
HPI
Status Determination &
Transport Decision
Ongoing
Assessment
Secondary Exam
Treatment
Vital Signs
Transfer of Care
C
General
Impression
Primary Exam
E
E
H
HPI
Scene Size-Up
A
Status Determination &
Transport Decision
Secondary Exam
Vital Signs
T
Treatment
Ongoing
Assessment
D
Transfer of Care
Time to stop talkin’ and
start doin’
PCR
TIMES
• 2043: Dispatch
• 2043: Enroute
• 2048: On
to scene
scene
• 2102: Enroute
• 2110: Arrival
Memorial ED
ED
In the pt’s own words!
General impression.
HPI/MOI/NOI
SAMPLE/OPQRST
Pertinent Negatives
Any other relevant information
Diagnosed
by
MD
Prescribed
Meds
Medication
Allergies
Any trauma noted? Pupil exam, any fluids in Ears/Nose/Mouth?
Mucus membranes moist with normal color? Facial droop or slurred
speech? Other exam finds?
Any trauma noted? JVD? Tracheal Deviation? Pn with palp or
movement? Other exam finds?
Any trauma noted to ant/lat/post chest? Equal chest rise/fall? Any
surgical scars? Are lung sounds clear & equal bilaterally? Other exam
finds?
Any trauma noted on spine? Any pn with palp or movement of
spine? Any surgical scars? Other exam finds?
Any trauma noted on spine? Any surgical scars? Any rigidity/guarding/
distension/rebound tenderness/palpable masses? Other exam finds?
Skin & Extremities:
Skin condition? Any trauma noted? Any pronator drift? Any issues
with CSM to any extremity? Other exam finds?
1411
1411
1413
1417
1418
C-spine immobilization, MJT, OPA insertion
BVM vent 12/min c O2 15 lpm
Vomit suctioned from airway
Cervical collar applied
Full spinal immobilization on longboard
1419
Transport to SRMH C3
1411
1415
1415
110/min 4/min
118/min 4/min
122/min 4/min
1420
126/min 6/min
Joe EMT
Joe EMT
N/A
68/36mmHg
66/34mmHg
N/A
90%
92%
2/2/4
2/3/4
2/3/4
72/38mmHg
93%
3/3/4
Jane EMT
Jane EMT